How do proper isolation procedures impact infection control?

There are many proper isolation contributions that impact infection control. Some serve to prevent the transmission of infectious agents in all health care settings. For example, proper environmental control decreased the risk of life-threatening fungal infections in the most severely immunocompromised patients, which led to the updated components of the protective environment; the establishment of a safety culture influenced healthcare workers' adherence to recommended infection control practices; and the knowledge of the prevention of transmission of multi-drug resistant organisms created a need for more specific recommendations for surveillance and control of these pathogens that would be practical and effective in various types of health care settings.

What elements of proper isolation procedures are necessary for infection prevention and control?

The elements of a proper isolation need to be performed to prevent disease transmission. See below some listed elements:

1. Standard and Expanded Precautions:

Hand hygiene observed before and after patient contact

Gown, gloves, mask not required for health care workers (HCWs) or visitors for routine entry into the room

Use of gown, gloves, and mask by HCWs and visitors according to Standard Precautions and as indicated for suspected or proven infections for which transmission-based precautions are recommended

Directed air flow; air supply and exhaust grills located so that clean, filtered air enters from one side of the room, flows across the patient’s bed, and exits on the opposite side of the room

Positive room air pressure in relation to the corridor; pressure differential of 2.5 Pa (0.01-inch water gauge)

Air flow patterns monitored and recorded daily using visual methods (e.g., flutter strips, smoke tubes) or a hand-held pressure gauge

Self-closing door on all room exits

Back-up ventilation equipment (e.g., portable units for fans or filters) maintained for emergency provision of ventilation requirements for PE areas, with immediate steps taken to restore the fixed ventilation system

For patients who require both a PE and an airborne infection isolation room (AIIR), use an anteroom to ensure proper air balance relationships and provide independent exhaust of contaminated air to the outside, or place a HEPA filter in the exhaust duct. If an anteroom is not available, place patient in an AIIR and use portable ventilation units, industrial-grade HEPA filters to enhance filtration of spores.

There are three isolation categories that reflect the major modes of microorganism transmission in nosocomial setting: contact, droplet and airborne. The rooms of the patients requiring contact precaution should be clearly marked with signs containing instructions regarding the type of precaution. It is important to make sure that the isolation procedure is being done and hospital policies are enforced.

There are no clinical trials to show the value of Isolation Procedures. The key conclusions derive from experience and from a sense of biological plausibility including hand hygiene.

Various forms of isolation have been applied in attempt to reduce the spread of healthcare associated infections. They include contact with blood, other body fluids or secretions and excretions. These precautions also serve to reduce the risk of transmission of infectious agents between patient and healthcare worker, even if presence of an infectious agent is unknown or not apparent. It is strongly recommended to perform hand hygiene before and after every patient contact; to use gloves, gowns and eye protection in situations in which exposure to body secretions or blood occurs; to perform hand hygiene after gloves are removed.

In the interest of safety, it is also recommended to provide a safe disposal of sharp instruments and needles in impervious containers; to have a safe injection practices for avoiding hepatitis B or C transmission (for example); to use mask when prolonged procedures involving puncture of the spinal canal are performed (epidural anesthesia, for example); respiratory hygiene/ cough etiquette, which applies to all patients and family members who have any sign of respiratory illness such as cough, congestion, or rhinorrhea. There are many opportunities for avoiding infection. The risk of inadvertent contamination of skin and clothing despite use of personal protective equipment (PPE) may be particularly high during removal of contaminated equipment. Taken together these recommendations are reasonable, safe, inexpensive, and consistent with a safety culture for patients and healthcare workers.

What are the consequences of ignoring proper isolation procedures for infection control?

Hand hygiene is the single most important measure to reduce the transmission of microorganism from one person to another or one site to another on the same patient. If healthcare workers ignore this most important concept, they will put patients in risk for acquiring infections in the hospital setting and facilitate the dissemination of different organisms such as the multi-drug resistant organisms, Clostridium difficile and all the others that can be related to outbreaks in hospitals.

Gloves must also be changed between patient contacts since many studies show that they become contaminated with MDR organisms. Sometimes, it is necessary to change heavily contaminated gloves while caring for a single patient to prevent cross-contaminated of body sites or if contamination of portable equipment is likely to occur. Such contaminations may contribute to the spread of pathogens known to survive on fomites, such as Acinetobacter species and vancomycin-resistant enterococci (VRE).

Frequent hand washing may cause skin damage and irritation, with resultant changes in microbial flora, increased skin shedding and the risk of transmission of microorganisms. Alcohol-based preparations with emollients also require less time than chlorhexidine gluconate to effect maximum reduction in bacteria counts and are at least as tolerable on skin as are antiseptic detergents.

Adverse events for patients on proper isolation procedures can occur. Healthcare workers generally spend less time with patients on proper isolation. Other general process of care measures, such as inappropriate documentation of vital signs and days without a physician note or nursing note were worse in contact precaution patients. Contact precautions are associated with increased symptoms of depression and anxiety and with decreased patient satisfaction with care.

What other information supports the research regarding proper isolation procedures?

Healthcare workers involved in the direct care of patients on contact precautions should wear nonsterile gloves for all patient contact. Masks should be used to protect healthcare personnel from infectious material from patients and to limit spread of infectious respiratory secretions from patients who are coughing. It must be emphasized that particulate respirator needs to be used by healthcare worker protection for limiting the tuberculosis transmission in healthcare setting.

Gowns are required if there is likely to be substantial direct contact with the patient or any infective material.

Medical equipment (stethoscopes as an example) should be dedicated to a single patient on isolation when possible, to avoid transfer of pathogens via fomites. Equipment that must be shared should be cleaned and disinfected before use for another patient.

It is necessary to implement an education program to reduce contamination during PPE removal when caring for patients with a suspected or confirmed Ebola virus infection. Another important approach is to redesign the PPEs to provide products that are easy to remove while minimizing the risk for personnel self-contamination.

In summary, we need to assume that every person is potentially colonized or infected with an organism that could be transmitted in the healthcare setting, and we need to apply these infection control practices discussed above during the delivery of health care.

Summary of current controversies.

Contact precautions are recommended to reduce the transmission of multidrug-resistant organisms (MDROs). However, the optimal method for control of MDROs (e.g., Methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant enterococci [VRE] and carbapenem-resistant Enterobacteriaceae [CRE]) remains unclear, and infection control practices remain controversial. Some authorities in infection control recommend active surveillance cultures to detect colonization with MRSA, VRE, and CRE so that contact precautions may be employed quickly and more broadly.

However, barriers to widespread implementation exist. Some hospitals have found that widespread implementation of these cultures is prohibitively expensive and their value not yet documented. Those who advocate routine screening have not yet shown a decrease in the Total Infection Rates. Concerns exist about the accuracy of current screening methods because perirectal swab cultures are only 58% sensitive for the detection of VRE. Furthermore, patient safety concerns have also been raised. Recent data suggest that patients placed in contact precautions are not significantly more likely to experience adverse events (including falls, electrolyte disturbances, and pressure ulcers). However, patients can express dissatisfaction with their care, and have less documented care by physicians and nurses than noncontact isolation patients.

There is very low quality evidence that double gloving and CDC doffing (removing) personal protective equipment (PPE) guidance decreases the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training.

What is the impact of proper isolation procedures relative to the impact of other methods of infection control?

Proper isolation procedures are components of best medical practices in hospitals. Improving hand hygiene practices requires an integration of infection control into the organization's safety culture. Several hospitals have linked measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body fluids. There other benefits too. Other hospitals have taken specific steps toward improving the safety culture, including error-reporting mechanisms, root cause analyses of identified problems, safety incentives, and employee education.

Some authorities have also observed that healthcare worker's adherence to recommended infection control practices decreases the transmission of infectious agents in health care settings.

The Institute of Medicine initiated a campaign entitled "5 Million Lives Campaign" that included measures to reduce specific nosocomial infections including hand hygiene, active surveillance cultures, decontamination of the environment and equipment, contact precautions for infected and colonized patients, and the use of bundles (central line bundle, ventilator bundle and bladder bundle). They also incorporated the check-list culture for controlling all steps involved in the infection prevention.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and proper isolation procedures.

See Table I for a summary of the current research.

Table I.

Summary of research surrounding proper isolation procedures and infection control

Authors

Setting

Design

Effect

Limitations

Implications

Type of isolation

Klein et al, 1989

Pediatric ICU

Safety monitoring of randomized controlled trial of CP

Safety monitoring revealed no difference in number of contacts/care at days 0, 1, 7 between 25 CP and 25 non-CP patients

All HCWs spend less time with patients on CP, which is not explained by severity of illness

C, D

Stelfox et al, 2003

Two large North American teaching hospitals

Two cohort studies: a general cohort and a disease-specific cohort study

Isolated patients were twice as likely as control patients to experience adverse events during hospitalization (31 vs. 15 adverse events per 1,000 days, p<0.001).Isolated patients complain more about their care than control patients (8% vs. 1%, p<0.001).

The definition of medical error and the difficulty to detect adverse events

CP patients experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care

C

Trick et al, 2004

Long term-care facility

Random allocation of two similar sections

Resident acquisition of antimicrobial-resistant organisms was no different in the glove-use and CPs sections (31 episodes (1.5 per 1,000 resident-days) vs. 38 episodes (1.6 per 1,000 resident-days).CPs were 40% more expensive than those of routine glove use.

Severity of illness not calculated

Routine glove use for HCWs may be preferable in many long-term care facilities

C

Bearman et al, 2007

Medical ICU

A prospective before-after trial: 3 months of standard practice in CP and 3 months of universal gloving (UG) and no CPs

Compliance in CP vs. in UG was 75.7% vs. 87%, respectively (p<0.001).Hand hygiene compliance before patient care was 18.7% in CP vs. 11.4% in UG, p<0.001.No difference in MRSA and VRE acquisition between the two cohorts

Short follow-up period and small sample size

UG was significantly greater than compliance with CP (gown and gloves), however greater compliance with hand hygiene was observed in the standard care phase (with CPs)

C

Cohen et al, 2008

Pediatric ward

Case control study (24 CP and 41 non-CP)

No significant difference in the time spent in direct patient care

Interviews with patients. Questionnaire.

No difference in either direct patient care or quality of care

C, D, A

Gilbert et al, 2009

Medical and Surgical ICU

Cohort: observed 506 patients (75 on CP) for the MICU and 345 (49 on CP) for the SICU

MICU and SICU had similar hand hygiene rates in CP rooms vs. in non-CP rooms.The MICU nurses had a higher rate of hand hygiene compliance in CP than in non-CP (66.7% vs. 51.6%, respectively, p<0.05).

Hawthorne effect for hand hygiene (the observer's known presence in the units may have affected compliance)

Overall hand hygiene compliance among HCWs is similar for patients in CPs compared with those non in isolation

C

Loeb et al, 2009

8 tertiary care Ontario hospitals

A randomized controlled trial

446 nurses were enrolled and randomly assigned the intervention; 225 in surgical masks vs. 221 to N95 respirators.Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group, p=0.86

The use of gowns and gloves and hand hygiene compliance was not monitoredThe acquisition of influenza in community or in hospital was not possible to determine

The use of a surgical mask compared with an N95 respirator resulted in non-inferior rates of laboratory-confirmed influenza.

D

Clock et al, 2010

3 hospitals in New York City

Observational study about CP compliance

CPs were present for 85.4% of indicated patients.VRE and MRSA were responsible for the greatest proportion of contact days.Adherence rates for all entry and exit behaviors were significant greater in ICU than in non-ICUs (all p<0.05)

Short follow-up period

Methods to monitor CP and identify and correct non-adherent practices should be a standard component of infection prevention and control programs.

C

Bearman et al, 2010

Surgical ICU

A prospective before-after trial: 6 months of standard CPs and 6 months of UG with emollient-impregnated gloves and no CPs

5. Gown use is time-consuming and may have a negative impact on patient care.

What national and international proper isolation procedure guidelines exist?

The guidelines for isolation precautions was intended for use by infection control staff, health care epidemiologists, health care administrators, nurses, other health care providers, and persons responsible for developing, implementing, and evaluating infection control programs for health care settings across the continuum of care.

A multidisciplinary committee consisting of healthcare professionals from the United States, Canada, and Europe with experience in cystic fibrosis care and healthcare epidemiology/infection control reviewed the relevant literature and developed evidence-based recommendations grade according to the published peer-reviewed supportive data. The participants chose to use the following CDC/HICPAC system for categorizing recommendations based on previous experience in crafting infection control guidelines beyond cystic fibrosis.

Transmission of M. tuberculosis is a recognized risk to patients and HCWs in health-care facilities. Transmission is most likely to occur from patients who have unrecognized pulmonary or laryngeal tuberculosis (TB), are not on effective anti-TB therapy, and have not been placed in TB isolation. Several recent TB outbreaks in health-care facilities, including outbreaks of multidrug- resistant TB, have heightened concern about nosocomial transmission. Patients who have multidrug-resistant TB can remain infectious for prolonged periods, which increase the risk for nosocomial and/or occupational transmission of M. tuberculosis. Although completely eliminating the risk for transmission of M. tuberculosis in all health-care facilities may not be possible at the present time, adherence to these guidelines should reduce the risk to persons in these settings.

What other consensus group statements exist and what do key leaders advise?

Other consensus group stressed that the basic practices of infection control in the inpatient setting also need to be applied to the outpatient setting, including the need to collect data on infection rates, develop formal policies and procedures, and intervene directly to prevent infections.

The Institute of Medicine initiated a Protecting 5 Million Lives Campaign that included measures to reduce certain nosocomial infections as central venous catheter-related bloodstream infection, ventilator associated pneumonia, surgical site infection, urinary tract infection associated to urinary catheter and MRSA infection. The plan included five components: active surveillance cultures, hand hygiene, decontamination of the environment and equipment, contact precautions for infected and colonized patients, and the use of device bundles (central line bundle and ventilator bundle).

(This document was intended for use by infection control staff, health care epidemiologists, health care administrators, nurses, other health care providers, and persons responsible for developing, implementing, and evaluating infection control programs for health care settings across the continuum of care.)

(It is emphasized the importance of monitoring adherence to isolation in a continuous manner and preferably with trained observers, because the justifications for non-compliance are large and frequent as it takes to put patients in isolation after employees had contact with patients, lack of supplies on hand hygiene opportunities, continuing education to health professionals and foreign visitors and as cleaning staff, especially those repeatedly noncompliant.)

(The study was conducted in five wards (three intensive care units and two medical wards) in a French university hospital. Failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene and carried a high-risk of microbial transmission.)

(Morgan et al in 2009 reviewed 15 studies in the literature on contact isolation. They identified four potential adverse effects more common: (1) Less contact between health professionals and patients. (2) Major non-infectious adverse effects such as pressure ulcers and falls in addition to more time to attend events. (3) the highest incidence of depression and anxiety of patients. (4) Decreased patient satisfaction compared to the service offered by the hospital.)

(Patients satisfaction was adversely affected by isolation if patients were kept uninformed of their healthcare. Patient safety was also negatively affected, leading to an eight-fold increase in adverse events related to supportive care failures.)

(In this prospective study a higher adherence of staff using gloves was found with universal gloving versus the use of procedural barriers to prevent contact (gloves and gowns). However, in the group with gloves only, universal adherence to hand hygiene was significantly lower when compared with the other group. In this study an increase was observed in the number of nosocomial infections with MDRs in the gloves only group. This finding was attributed to the lower hand hygiene compliance in the group using only gloves and the short duration of study observation.)

(It was shown in this prospective study in a surgical ICU that healthcare workers' compliance with use of impregnated gloves with emollients was significantly higher when compared to the compliance with universal use of gloves with gowns (contact precaution). It was also found that hand hygiene compliance was higher in the gloves and gowns group with no plausible explanation at the time of the study. In any case there was no significant increase in the healthcare associated infections in both groups.)

(Regular monitoring showed that the children in each group were touched and handled comparably often by hospital personnel and family members. The conclusion was that the use of disposable, high-barrier gowns and gloves for the care of selected, high-risk children who require prolonged intensive care significantly reduces the incidence of nosocomial infection, and it is well tolerated, and does not compromise the delivery of care.)

(Universal use of gloves and gowns was no better than universal use of gloves only in preventing rectal colonization with vancomycin-resistant enterococci in a medical intensive care unit of a hospital in which vancomycin-resistant enterococci are endemic. Because the use of gowns and gloves together may be associated with better compliance and may help prevent transmission of other infectious agents, this finding may not be applicable to outbreaks caused by single strains or hospitals in which the prevalence of vancomycin-resistant enterococci is low.)

(Healthcare workers are half as likely to enter the rooms of patients in contact isolation, but are more likely to wash their hands after caring for them than after caring for patients not in isolation.)

(From 1 July 1997 through 30 June 1998 and from 1 July 1999 through 31 December 1999, health care personnel and visitors were required to use gloves and gowns upon entry into rooms where there were patients infected with nosocomial pathogens. From 1 July 1998 through 30 June 1999, only gloves were required under these same circumstances. During the gown period, 59 patients acquired VRE (9.1 cases per 1000 MICU-days), and 73 patients acquired VRE during the no-gown period (19.6 cases per 1000 MICU-days; P

(For 2 hours per day over a 5-week period, a single observer recorded provider/patient contact in adjacent isolated and nonisolated patient rooms on both the surgical intensive care unit (ICU) and surgical wards of a university hospital. Isolated patients were visited fewer times than nonisolated patients (5.3 vs 10.9 visits/h, P

(The results of this study demonstrate a strong association between patient isolation and shortfalls of processes, outcomes and satisfaction. Hospital infection control policies may prevent the spread of communicable infections but may also inadvertently lead to poorer quality of care and adverse events.)

(A randomized trial comparing the fit-tested N95 respirator with surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. The use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.)

(A multidisciplinary committee consisting of healthcare professionals from the United States, Canada, and Europe with experience in cystic fibrosis care and healthcare epidemiology/infection control reviewed the relevant literature and developed evidence-based recommendations grading according to the published peer-reviewed supportive data. The participants chose to use the CDC/HICPAC system for categorizing recommendations based on previous experience in crafting infection control guidelines beyond cystic fibrosis.)

"Health Canada, Nosocomial and Occupational Infections Section. Development of a resource model for infection prevention and control programs in acute, long-term, and home care settings: conference proceedings of the Infection Prevention and Control Alliance". Am J Infect Cont.
vol. 32. 2004. pp. 2-6.

(It is stressed that the basic practices of infection control in the inpatient setting also need to be applied to the outpatient setting, including the need to collect data on infection rates, develop formal policies and procedures, and intervene directly to prevent infections.)

(In this cluster randomized trial involving intensive care units (ICUs), the authors evaluated the effect of surveillance for MRSA and VRE colonization and the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in that setting. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. The results showed that the intervention was not effective in reducing the transmission of MRSA or VRE although the use of barrier precautions by providers was less than what was required.)

(In this matched prospective cohort study, there were significantly fewer noninfectious adverse events for patients on contact precautions compared with patients not on contact precautions. The observed results of contact precautions were unexpected and in the opposite direction of the authors' hypothesized increase in risk.)

(This cluster randomized trial in adult ICUs found that universal glove and gown use had an impact on the overall rate of adverse events, including subtypes of infectious, noninfectious, preventable, or severe adverse events.)

(This is a quasi-experimental study of a multifaceted infection control program for reducing carbapenem-resistant Enterobacteriaceae [CRE] transmission and bloodstream infection [BSIs]. The results of this study showed that targeted screening and cohorting of CRE carriers and infections, combined with cleaning, education, and antimicrobial stewardship measures, significantly decreased the institutional incidence of CRE BSI, and colonization.)

(This controlled quasi-experimental study showed that detecting and isolating C. difficile carriers was associated with a significant decrease in the incidence of healthcare associated-Clostridiumdifficile infection.)

(The author's conclusions from this study very low quality evidence exists that double gloving and CDC doffing (removing) personal protective equipment (PPE) appears to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training.)